Trepanation in ancient times

Trepanation has been practiced since thousands of years. It is possibly
one of the earliest forms of surgical intervention on the head of which
we have any authentic record and its practice is widely spread in space
and time. Trepanation of the human skull is the removal of a piece of
calvarium with out damage to the underlying blood-vessels, meninges and
brain. In some parts of the world it is still practised in its early form
by native medicine men. Trepanation as performed by man in prehistoric
and early historic times shows an astonishing degree of technical skill.
And certainly the number of survivals of this operation testify to the
competence of the early surgeons. For a long time medical science doubted
the existence of healed prehistoric trepanations, since eighteenth and
nineteenth century surgeons of the pre-antiseptic era rejected this procedure
owing to the almost one hundred per cent mortality (Schröder, 1957). However,
as evidence of trepanation appeared in the South Sea Islands and in North
Africa, these doubts were gradually removed. According to Rytel (1962)
the first reference to trepanation dates from 1849 (Atlas de Morton, Cranea
Americana). Bartucz (1964) claims that Dr. E. Kovaces of Hungary was the
first to describe in 1853 an actual trepanation found at Vereb. Another
of the earliest to be recognized as such was noted by E.G. Squier on a
skull from Cuzco during his tour of 1863-65 through Peru (Stewart, 1958).
He consulted Paul Broca, the noted French physical anthropologist of the
time whose interest led to the recognition of Neolithic trepanations in
France. And thus gradually more skulls came to light showing this early
surgical interference. The realization that this practice has survived
until the present day has greatly increased our knowledge of this operation.
The most important contributions on this subject are the study by Guiard
(1930), the survey of European trepanations by Piggott (1940) and the
more recent general review by Stewart (1958). This particular account
will deal with the prehistoric and early historic aspects of trepanation
and note certain of its mediaeval features.

A summary of the distribution of the various sites so far found in the
world is given below together with the names of some of the main authors.
The list is not fully comprehensive since the literature is rather scattered
and new discoveries are frequent but it does indicate how wide spread
the practice was. In each case the name of the country is followed by
the number of sites found and the authors referred to. With regard to
ceratin countries, although no actual case of trepanation has as yet come
to light, there is strong presumptive evidence from the literature that
it was practised. .

Here only the main outlines will be given together with certain additional
information that has become available in recent years. Moodie considers
that the earliest European trepanations occurred some ten thousand years
ago and Forgue (1938) too places the beginnings at the end of the Palaeolithic
period. All these estimates, however, are hypothetical. It has been accepted
by Broca, Lucas-Championnière (1878), Horsley (1888), Ruffer, Guiard,
Parry (1923), Piggott and Oakley et al. That this operation was practised
during the Neolithic age. Piggott and Oakley et al. State that trepanation
was performed occasionally by early Danubians (c. 3000 B.C.) and frequently
by "battleaxe" people who constructed the chambered tombs in the Seine-Oise-Marne
area of France (c. 2000 B.C.). So many skulls showing this trait were
discovered in these tombs that it is probable that the operation had some
ritual significance (Oakley et al). I t seems that circa, 1900 to 1500
B.C., the south of France was a major centre for trepanation (Sudhoff,
1929; Stewart). Examples of this practice have also been reported from
many regions of Neolithic Europe, and in particular, Denmark, England,
Germany, Italy, USSR, the Balkans have revealed quite a large number of
skulls. In Europe trepanned skulls became rare after the Neolithic era,
partly because in the later Bronze age and La Tène period the dead were
mostly cremated (Regnault, 1936). Nevertheless a few examples are available
from France (Guiard), Scandinavia (Piggott), Germany (Brunn, Breitinger),
Czechoslovakia (Matiegka), Hungary (Bartucz), Rumania (Russu and Bologa),
Bulgaria (Boev), USSR (Bobin) and other countries. The Iron Age, early
Historic, Greek, Roman and Mediaeval times all indicate that trepanation
continued to be performed in Europe. This is known from actual specimens
of those days, and from the relevant literature of the later period. Mediaeval
evidence comes from England (McKenzie, Parry, Brothwell), Ireland (Martin,
Fleetwood), France (Piggott), Germany (Brunn, Karolyi), Italy (Castiglioni,
1941), Czechoslovakia (Piggott), Hungary (Boev), Rumania (Russu and Bologa),
Bulgaria (Boev) and other areas. According to Rytel, however, the frequency
of this operation never reached the proportions nor the universality during
Mediaeval times that it enjoyed in the Neolithic age. To this one has
to add that skeletons of the former period unfortunately have aroused
less interest than those of older burials and thus our knowledge in this
respect is rather scanty. In Greece, Hippocrates (c. 460 to 355 B.C.),
advises trepanation for wounds of the head in one of his six treatises
of his surgical classic (Littré). The account is detailed and meticulous
and shows some experience, and although little or nothing is known of
any actual specimens it is highly likely that this operation must have
been performed fairly often. Roman examples of this surgical interference
are known from Gaul and also from Trier in Germany (Piggott). And from
Rome we have the account by Celsus (c. 25 B.C. to 37 A.D. ) of a method
of operation which became standard in the surgical books of the Middle
Ages. This apparently was adopted later by the Arabs. Celsus, whose method
differed from that of prehistoric times, advises trepanation for head
wounds and gives careful and precise instructions on methodology in his
treatise De medicina (Spencer, 1948), and part of his De artibus, written
between 25 and 35 A.D. Although Spencer believes that Celsus was a medical
practitioner, Castiglioni (1941) considers that he was neither a physician
nor a surgeon but a compiler from the works of others. Which ever he was,
his text undoubtedly influenced the surgical world for many centuries.
Much later Rogerius Frugardi (c. 1170 to 1200 A.D.), otherwise known as
Roger of Salerno, one of the greatest of the Salernitan surgeons, produced
his text in which he deals at length with wounds of the head and brain,
even giving the differential diagnosis of injuries of the skull and indications
for trepanation (Castiglioni). However, his method was not dissimilar
from that of Celsus. From Ireland several interesting examples are available.
A trepanned skull of a thirteen-year-old child, probably early Christian,
was recovered from Collierstown in Co. Meath (Martin, 1935). Two further
trepanations each of late Mediaeval date, one from Ballinlough (Co. Laois)
and the other from Maganey Lower (Co. Kildare), were found during recent
excavations. A fourth specimen was discovered in a stone-lined grave at
the Abbey of Nendrum on Mahee Island in Strangford Lough (Martin). The
abbey was destroyed in 974 A.D. by fire. It is highly likely that in those
days "major surgery" was performed in monastic institutions (Fleetwood,
1951). Legend has it that Cennfaeladh, whose skull was fractured by a
blow from a sword during the battle of Moyrath in Co. Down (637 A.D. ),
was operated upon by St. Bricin, the Abbot of Tuaim Drecain, an accomplished
surgeon and scholar (Fleetwood). In Yugoslavia, especially the south-western
part, and also in northern Albania there is a long history of the practice
of trepanation which persisted as late as the nineteenth century (Giot
and Desse, Boev). The folklore of this region is rich in accounts of these
operations (Leskin, 1919). Thus, the story is told of the physician who
was secretly watched by his apprentice as he trepanned the forehead of
the daughter of the Czar and extracted a beetle from her brain. Outside
Europe and apart from South America, the evidence of examples and historical
accounts is more scant. This may be due to the fact that fewer exhumations
have been carried out in these parts and further excavations may reveal
more information. In Asia the examples from Palestine are of some interest.
There the oldest trepanation found so far comes from Jericho (Oakley et
al.) and dates to the Bronze Age (c. 2000 B.C. ). Risdon who excavated
Tell Duweir (Lachish) discovered three Iron Age (c. 8th cent. B.C. ) skulls,
which were reported on by Parry and Starkey (1936). Giles (1953) reported
a further case of trepanation belonging to that period. From Roman Syria
there is, for instance, indirect evidence by way of China (Needham, 1954).
Ouyang Hsiu and Sung Chhi in their Hsin Thang Shu (New history of the
T ang dynasty) in 1061 A.D. state that the people of Ta-Chhin (Roman Syria)
have physicians who can cure blindness by opening the brain and removing
worms. Needham believes this to be "the solitary instance of any attention
consciously paid in Chinese writing to early Western medical science."
Going further east one finds that both in ancient and recent times this
type of skull surgery was performed in the region comprising present day
eastern Afghanistan, northern Pakistan and Kashmir (Giot and Desse 1950;
Roney, 1954). Although actual specimens of the earlier periods are rare,
the lore of trepanation was very much current around c. 400 A.D. in that
part of the world (Müller, 1959) and in the Tibetan region (Jungbauer,
1923). One of the accounts mentions that in ancient times students went
to Takkasil_ (Greek Taxila) in the north-western part of the Indian subcontinent
to learn the arts and sciences. At that time a famous teacher _treya,
king of the physicians, lived there, to whom prince J_vaka went as an
apprentice so as to learn the art of opening skulls. He watches his master
extract a worm from the brain of a patient. And later when J_vaka returns
to his own country he trepans, using an "opening instrument" and thus
removes centipedes. Legend has it that he later became the medical adviser
to Buddha. J_vaka is certainly famous in old Buddhist tests and in folklore.
It is also known that these stories were carried eastward by Buddhist
missions. However, in China these tales received certain additions, such
as the use of acupuncture and feeling the pulse, which were not practised
in ancient India. Thus the folklore became Chinese by adaptation. On the
other hand the Tibetans took over the original stories and translated
them without alteration. Müller feels that these folktales, and there
are many, are based on fact and that trepanation must have been practised
in this in this area. So far the main part of China has not revealed any
trepanations (Woo, 1964), though a few have been found in her peripheral
provinces. Thus there is evidence from Tibet (Boev 1959), quite apart
from the folklore traditions (Jungbauer 1923). Here medical knowledge
probably came into the region through Kashmir. Tallgren (1936) reports
a skull with an occipital opening from Oglakty in southern Siberia which
was found in a cemetery dating to the Han dynasty (202 B.C. to 220 A.D.
). And Montandon (1926) found another example from the Far East in a museum
in Vladivostok; however, date and site are doubtful. These two regions
at one time, of course, belonged to the northern part of the Chinese empire.
Although there are only these few skulls, classical Chinese literature
does mention trepanation. In ancient times (c. 2700 to 1100 B.C. ) there
is supposed to have existed a physician Yü Fu who is alleged to have been
able to expose the brain (Wong and Wu, 1936). However, he is a very ancient
legendary character associated with surgery and, according to Needham,
one of the interlocutors in the great classic of medicine Huang Ti Nei
Ching, Su Wên (c. 2nd cent. B.C. ). Wong and Wu also mention Hua Tho (c.
130 to 220 A.D. ), the famous surgeon and discoverer of the use of anaesthetics.
Legend has it that he offered to cure the headaches of the Wei emperor
Tshao by opening the skull, an offer which was declined. Another account
supposes that Hua Tho suggested trepanation to a famous warrior who thought
the surgeon wanted to murder him and therefore had him beheaded. Reference
already has been made to the Buddhist missions. However, for the more
detailed information on classical China given below, the author is indebted
to Dr. Joseph Needham F.R.S. who kindly made this available. The Pao Phu
Tzu book, by the famous physician and alchemist Ko Hung, written circa
300 A.D. , is quoted by late scientific encyclopaedias as saying that
Thai Tshang Kung (Shunyü I 205 to 150 B.C. ) "used to cut open skulls
of patients and arrange their brains in order." Here it is rather difficult
to trace the original passage. Although there is some uncertainty, it
s probable that the trepanation account of Hua Tho occurs in the Yuan
period novel San Kuo Chih Yen I (The three kingdoms story) by Lo Kuan-Chung
(c. 1364 A.D. ). Nor is it known whether there are any more ancient accounts
of this operation nearer the time of Hua Tho himself among the unofficial
literature of the San Kuo or Liu Chhao periods. In 1040 A.D. there was
published a history of medicine entitled Li Tai Ming I Meng Chhiu (Brief
lives of the famous physicians of all ages) by Chou Shou-Chung. He quoted
two descriptions of trepanations from an earlier book, the Yü Thang Hsien
Hua (Leisurely conversations of academicians) written between 960 and
1040 A.D., i.e., during the Sung dynasty. This was also quoted in a later
florilegium, the Lei Shuo by Wang Jen-Yü in 1136. The first account is
of a metal worker who performed an operation for the extraction of a worm
from a patient previously pronounced incurable. The other tells of a Taoist
adept who was condemned to death for alleged arson, but who wished to
demonstrate his skill at surgery before dying; a leper was therefore fetched,
and the adept opened his skull and removed a cupfull of worms or parasites.
During this period too, the Hsin Thang Shu, quoted above, was published
and this mentions the surgical practices in Roman Syria. All this seems
to indicate that trepanation was probably practised during tenth and fourteenth
centuries in China. Later in 1366 the Cho Kêng Lu (Talks while the plough
is resting) by Thao Tsung-I appeared, in which it is said that Arabic
physicians, of which there had been many in China since T ang times, could
open the skull and extract worms. Thus we have the classical literary
references, but no actual skulls showing this operation. It is therefore
conceivable that in time the skeletal evidence will be forthcoming. The
Ainu people in Hokkaido, northern Japan, are also supposed to have practised
trepanation (Boev, 1959). Certainly Rytel (1962) mentions five Ainu skulls
showing resection of the foramen magnum and of the alveolar process, and
this evidence of surgical interference may indicate that other techniques,
e.g., trepanation were not unknown. Turning to Africa, one finds that
so far in Egypt only six trepanations have been found, although more Egyptian
skulls have been examined than of any other population. Chronologically
the excavations have revealed the following: the oldest find is from Sesebi,
Sudan (Lisowski, 1954) and belongs to the XVIIIth to XIXth Dynasty (c.
1200 B.C. ), Batrawi (1935) reported one from Sakkara dating to the XXVth
Dynasty (c. 600 B.C. ); a bilateral trepanation was found in Sakkara (Lisowski)
of possibly Ptolemaic date (c. 323 to 30 B.C. (, a Meroitic skull (c.
50 to 200 A. D. ) was reported earlier by Batrawi. Ruffer (1918) mentions
one of circa 200 A.D. found near Alexandria, and Elliot Smith and Wood
Jones (1910) described a Byzantine (395 to 638 A.D. ) trepanation from
Hesa near Aswan re-examined and also reported by Parry. In mentioning
the above examples one has to consider the possible connexions between
the practice of trepanation in Egypt and that practised in neighbouring
regions. The Egyptian specimens roughly fall into three historic periods.
To the first of these belong the Sesebi and the earlier Sakkara individuals
who were more or less contemporary of the Palestinian trepanations. It
is difficult, however, to relate these two centres since they are some
eight hundred miles apart. The later Sakkara specimen, which dates to
the Ptolemaic period, may be an example of the influence of Greek surgery.
The other trepanations belonging to the period 50 to 600 A.D. are probably
due to Roman influence. From North Africa there is evidence that the technique
this type of skull surgery has survived to the present day. Sudhoff (1929)
gave reports from Libya, Hilton-Simpson (1913) and Forgue (1938) described
the operative procedure from the Aures mountains in Algeria, and Oakley
et al. Gave a contemporary account of trepanation among the Tibu in Tebesti
(Sahara). It might be argued that here one finds a degenerate form of
Greek or classical surgery, though it is more likely that this practice
dates to Islamic times. In Kenya too trepanation is still performed to
this day (Sood, 1960; Margetts, 1962) where it may well have been introduced
by the Arabs. It is appropriate at this juncture when dealing with Asia
and Africa to mention trepanation in the old Islamic world, a period during
which their science and medicine flourished from the western borders of
China right across Persia to Egypt, North Africa and Spain. It appears
that the method of operation described by Celsus was adopted by the Arabs,
for it is advocated in the treatises of the tenth to eleventh century
surgeons Ali-abbas and Abdul-kassim (Piggott, 1940). In this connexion
mention is made already that Thao Tsung-I wrote in 1366 of the skill of
the Arabic physicians. In fact many of the latter had been in China since
T ang times. With regard to South America the centre for trepanations
was restricted largely to the central and southern parts of Peru and to
the neighbouring part of Bolivia (Cabieses, 1957). It appears that more
trepanned skulls have been found in this area than in all the rest of
the world together (Stewart, 1958). According to Stewart the oldest specimens
date to the period of c. fifth century B.C. to fifth century A.D. , although
Rytel (1962) considers that the oldest evidence of trepanation in Peru
dates to circa 3000 B.C. It is also known that the Indians of this particular
region continued these operations into post-Columbian times (Bandelier,
1904), and even today the practice of trepanation is not unknown (Oakley
et al.).

Since science and magic are in their early stages indistinguishable (Needham,
1954), it is difficult to differentiate between ritual or magical and
therapeutic motives underlying the practice of trepanation. Dealing first
with the performance of this operation in the living, one finds that various
authors emphasize different aspects of the motivation. Broca (1876) decided
that trepanations were performed for the relief of certain intracranial
maladies and Horsley (1888) considered that all these surgical interferences
were therapeutic. According to Lucas-Championnière (1912) the operation
was done in order to cure a disease supposed to have its seat in the head
or to remove splinters from a fractured skull---in the latter practicing
cerebral decompression. Ruffer believed that Neolithic people may have
trepanned for injuries, but as most of the operated skulls show no signs
of trauma, headache was probably the chief indication. Lucas-Championnière
also mentioned that "according to the theory usually accepted, the operation
was first performed from time immemorial on sheep for the relief of staggers,
and later man extended the application of the veterinary method to his
species." However, Ruffer felt that this was pure speculation. Russu and
Bologa (1961) also mention the practice of trepanation in connection with
staggers in sheep, and how the shepherds in Rumania thereby removed the
larva of the Multiceps multiceps since ancient times. Thus it could be
that the accounts in folklore of the extraction of beetles (Yugoslavia)
and centipedes (Tibet) from the brain in man might be based on the trepanation
of sheep, and may not be so far fetched as they might seem at first sight.
Moodie (1923), Piggott (1940), and Russu and Bologa consider that the
majority of operations were performed as a definite surgical treatment,
either to repair a fracture of the skull or to alleviate headache. Guiard
(1930), Regnault (1936), Forgue (1938) and Thompson (1938) believe that
in prehistoric times various intracranial diseases were ascribed to evil
spirits and therefore cure was obtained by letting these out of the skull.
And since these operations were often followed by improvement in the patient
s condition, the primitive surgeons persisted with this surgical intervention
(Forgue). Castiglioni (1941) considers that trepanation owes its origin
to a demonic or magic concept more than to the idea of therapy. In view
of the Peruvian evidence, Stewart believes that trepanations were mainly
performed in cases of skull fracture, though he does not exclude other
motives for this operation. However, Guiard considered that since the
procedure was such a frequent custom among the pre-Inca and Inca inhabitants
of Peru and Bolivia, it bordered on a cult. Oakley et al. who described
a skull from Tarkhan with a parietal craniotomy and which also shows signs
of otitis media and mastoid inflammation, believed that in this case the
operation must have been undertaken for clinical reasons. More recently
Rytel stated that the surgical indications were both therapeutic and superstitious.
Owing to the large number of trepanned skulls found in the chambered tombs
in the Seine-Oise-Marne region of France Oakley et al. feel that here
the operation had some ritual significance, though they consider that
in other geographic regions the indications may have been of a clinical
nature. Our knowledge of prehistoric trepanation would be very poor indeed
were it not for the fact that we know something about the practice of
this operation in classical times and in the more recent past, and that
it still is performed in widely separated parts of the world. In Hippocratic
times medicine in Europe was no longer a branch of magic and religion
but had begun to gain its own rightful place (Guthrie, 1958). Thus one
finds that for wounds of the head Hippocrates advised early trepanation---
within three days for contusion of bone, and secondary trepanation for
infectious accidents---before the fourteenth day in winter and before
the seventh day in summer (Littré). In his writings Celsus also notes
that for cranial injuries trepanation is indicated (Spencer). And later
in mediaeval times Rogerius Frugardi gives the same advice (Castiglioni).
At the beginning of the last century Cornish miners insisted on having
their skulls opened following injuries to the head (Lucas-Championnière).
As late as the nineteenth century trepanations were performed in south-western
Yugoslavia and northern Albania (Russu and Bologa) in cases of skull trauma
and in nervous and mental diseases; and in the case of a blood feud where
a person was marked for revenge the latter could escape by voluntary submission
to this operation. From Algeria (Hilton-Simpson) it is known that in certain
cases of head injury, usually a fracture resulting from blows from sticks
or stones, trepanation is indicated, however, this surgical procedure
is more often performed in cases of persistent headache. In present day
Kenya where this operation is still practised, the most common indication
is headache (Sood). Crump (1901) noted that trepanation was performed
in Melanesia not only in cases of headache, epilepsy and insanity, but
also as an aid to longevity. Ford (1937) studying this operation in the
same group of Pacific islands, says that it was used in cranial injuries
due to warfare, and for headaches and in some children of three to five
years of age women cut openings into the foreheads to ward off future
trouble from trauma---possible an extension of surgical therapy to prophylaxis.
And in Bolivia medicine-men still perform trepanation for head injuries
(Oakley et al.). As a result of investigations among populations that
still trepan Wölfel (1925) believes that injuries caused by blows and
stone-slings are the main indications for trepanation. On the basis of
Neolithic material in Denmark, Fischer-Møller (1936) comes to the same
conclusions and goes on to observe that with the appearance of metallic
weapons and helmets the neck proved to be a more vulnerable region for
inflicting fatal injuries than the head. Russu and Bologa (1961) are of
the opinion that the practice of trepanation may be related to the spread
of the stone-sling and that only later on this surgical measure was used
in other disease in which the presenting symptoms were similar to those
following cranial trauma. The motive for posthumous trepanation was to
obtain roundels of human skull bone (Dechelette, 1908). Apparently the
object was to remove a piece of bone from the dead skull of one previously
trepanned which included a bit of the healed rim from the earlier successful
operation (Piggott). This type of trepanation was undertaken in prehistoric
Europe and is practised in parts of Africa today (Oakley et al.). These
roundels were usually of circular shape and often perforated and polished
so as to be worn as a necklace. They had a superstitious significance
and were used as charms, or amulets, or as a talisman to counter the demons
(Broca, Regnault, Forgue). Even up to the Middle Ages it was supposed
that powdered cranial bones possessed curative powers while roundels were
worn as late as Gallic times (Ruffer). Thus one may summarize the motives
for trepanation in the living and the dead as follows. In the living the
indications can be considered under three headings: Therapeutic, certainly
in Hippocratic and later times: for head injuries such as fractures, especially
depressed fractures, scalp wounds with or without an inflammatory process,
concussion; and possibly in cases of lesions of a syphilitic nature in
Peru (Rytel). Magico-therapeutic, where in a sense the cause was considered
to be evil spirits which had to be let out and the effect could be "therapeutic"
at times: headaches, vertigo, neuralgia, coma, delirium, intracranial
vascular catastrophies, meningitis, convulsions, epilepsy, intracranial
tumours, mental diseases. And prophylactically to ward off trouble such
as head injuries and to promote longevity in Melanesia (Crump). Magico-ritual:
e.g., as a ritual act in central France (Oakley et al.); in cases of feuds
(Russu and Bologa). The indications for post-mortem trepanation seem to
have been in order to secure roundels for amulets.

In general craniotomies were performed on the left side (Guiard, Forgue,
Piggott, Stewart). The reason for this (Russu and Bologa) was that traumatic
lesions of the skull doe to blows occurred in the majority of cases on
this side since the adversary, usually right handed, was opposite the
victim. Most authorities (Lucas-Championnière, Ruffer, Moodie, Guiard,
Forgue, Piggott) consider that in Europe the parietal bone was the most
frequently trepanned skull element, followed by the frontal, occipital
and rarely the temporal bones. Although Piggott points out that in a high
proportion of Czechoslovak trepanations the frontal region was involved.
Ruffer suggests that the high frequency of parietal selection was because
this region was most easily accessible to the operator. The latter, squatting
in front or behind the patient, held the head with his left arm or fixed
it between his knees and operated with his right hand. It is of course
well known that traumatic subdural haemorrhages can occur following blows
in the parietal region. The first detailed side and site analysis was
made by Stewart (1958) who, studying a series of 112 trepanations from
Peru, found that 48.2 per cent had been operated on the left side, 29.5
per cent on the right, and 22.3 per cent in the median line. Of these,
53.6 per cent had been trepanned in the frontal region, 33.0 per cent
in the parietal and 13.4 per cent in the occipital area. The frontal region
also was the elected site for prophylactic trepanation in Melanesian infants
(Ford). Lucas-Championnière (1912) claimed that the sagittal suture was
carefully avoided, implying that the primitive surgeons had some idea
of the underlying anatomy of the superior sagittal sinus. Hilton-Simpson
(1913) went so far as to state that sutures were never involved in trepanations.
He based his views on his studies of the practice of craniotomy in the
Aures mountains in Algeria, where the medicine-man observed two rules:
that the opening must not involve the sutures and the dura mater must
remain intact. That these views are not correct can be seen from observation
of trepanned material in which the craniotomies have cut across the sagittal
and other sutures and from the work of Stewart who has clearly shown that
the sagittal, coronal and lambdoid sutures were quite often involved.
Guiard and Maxia and Cossu also stated that the sutures were never respected.
For anaesthetic purposes the use of alcohol was not unknown in many parts
of the world. Guiard states that the Serbians used grape wine and the
people Uganda palm wine, while the ancient Egyptians according to Parry
and Sudhoff knew in addition the uses of opium. Similarly the Inca made
use of alcohol as well as various preparations from the coca plant (Rytel).
Oakley et al. report that for present day trepanations in Bolivia the
medicine-men use chicha, a local drink, as an anaesthetic. However, it
must not be forgotten that in cases of skull injury the patient often
was unconscious thus facilitating sugical intervention, a fact that applied
to most cases in Melanesia (Ford). On the other hand the Kabyles according
to Hilton-Simpson never use anaesthetics when trepanning. The earlier
trepanations were performed most likely with the aid of instruments made
of flaked stone, especially flint, of obsidian and of bone (Ruffer, Parry,
Thompson, Stewart, Rytel). Probably other materials such as wood were
employed also as aids. Later, instruments made of hardened copper were
used which were fashioned with a rough edge and shaped like a wedge so
as to prevent sudden penetration through the skull bone (Thompson). Russu
and Bologa (1961) describe a saw of the La Tène period, discovered in
Rumania, which they think was a trepanation instrument. This was found
together with a cremation and various ceramics typical of a Celtic burial
dating to circa second century B.C. The interment may have been that of
a medicine-man. This well preserved saw is 11 cm long, has a half-moon-shaped
blade and continues into a swan-neck-shaped stem which ends in a straight
handle. The whole instrument is made out of one piece of iron, whose blade
is thinner towards the serrated cutting edge and thicker towards the base.
This wedge-shape would prevent the saw from cutting deeper than 5 mm to
7 mm into bone. Sudhoff and Ebert (1913) described a number of surgical
instruments of the La Tène period which were found in Hungary. One of
these is a bone saw while the others are retractors and elevators. The
two authors believed that these were amputation instruments. However,
Holländer (1915) who re-examined them considered that they were much too
fine for such a brutal operation as amputation. He had the saw reconstructed
and found that it could only be used on the skull since its blade was
wedge-shaped thus limiting the depth of the saw cut. From this Holländer
concluded that the instrument must have been employed in trepanning. The
trepan was already in use at the time of Hippocrates and was held either
between the palms and rotated by rubbing the hands together or rotated
by a cross-piece and thong (Littré). Celsus described various trepans,
a meningophylax for holding back the meninges when the border of the trepanned
opening is manipulated and an instrument for removing the bone fragments
following craniotomy (Spencer). Instruments such as these were excavated
at Pompeïï (Castiglioni). A more complete outline of the historic evolution
of the various trepans from Hippocratic to recent times is given by Thompson
(1938). In Algeria a variety of instruments such as scalpers, retractors,
drills, saws, screws and elevators, were used (Hilton-Simpson) which will
be mentioned when dealing with the methods of craniotomy. Sood has described
to me the retractors, saws and elevators, mostly made of flattened nails,
still used by medicine-men in Kenya. In Melanesia, the sharp edges of
shells were utilized in addition to obsidian for making the skull openings
(Crump). Ford further reported that shark s teeth as well as broken bottles
and razors were used on these islands in more recent times. In South America
during the classical Inca period a special T-shaped knife or "tumi" was
employed for trepanation (Cabieses). This instrument has been adopted
by the Peruvian Academy of Surgery as their emblem. According to the literature
(Littré, Broca, Lucas-Championnière, Ruffer, Parry, Guiard, Forgue, Piggott,
Spencer, Stewart, Rytel) several methods of operation have been described,
some of which are shown in Figure 1. 1. The scraping technique consists
in removing the required area of bone by gradually scraping away, first
the lamina externa and diploë, and then with considerable care the lamina
interna to expose the dura mater. The resulting opening has of necessity
widely bevelled edges and the removed part is in powder form Fig. 1, Number
1). This was probably one of the most common methods used, surviving even
into the Italian Renaissance period (Piggott). In Rumania this procedure
was practised only in mediaeval times (Russu and Bologa). For illustrative
purposes an Egyptian trepanation is shown (Fig. 2). 2. The grooving method,
in which a series of curved grooves are drawn and redrawn on the skull
with a sharp instrument, until the bone between the grooves becomes loose
and can be removed (Fig. 1, number 2). Probably this was the procedure
by which roundels were obtained (Fig. 3). This technique was also very
frequently used in many parts of the world and is still performed at the
present day in Kenya (Sood). Russu and Bologa state that this was the
method of choice in prehistoric times in Rumania. In general the orifice
in the external lamina is larger than the one in the internal lamina,
thus giving a rather bevelled appearance. Ruffer believed that this was
always the case, but according to Guiard certain trepanations whose diameter
does not surpass 2 cms present practically perpendicular borders to the
plane of the surface of the skull and are always circular. 3. In the boring-and-cutting
technique the bone is perforated by a circle of closely adjoining perforations
extending to the internal lamina, which are then connected by cuts with
a sharp instrument, the latter more or less completely obliterating the
serrated border. Finally the freed fragment is levered out (Fig. 1, number
3). Lucas-Championnière considered that this type of operation was used
in prehistoric times and based his supposition entirely on a single skull
from Peru. On the other hand Stewart believes that this method probably
was not practised outside Peru and there only occasionally. However, the
boring-and cutting procedure was described by Celsus in Roman times (Spencer).
He advised in cases of more extensive cranial injuries that a hole is
drilled with a trepan at the junction of the diseased and sound bone,
close to this a second and a third, until the whole area is ringed by
these perforations. Then a chisel is driven through from one hole to the
next and so the intervening bone is removed. This surgical operation was
later adopted by the Arabs and became standard in the Middle Ages. Thus
Rogerius Frugardi recommended that in cases of depressed fractures a number
of perforations are made around the affected area with a trepan and then
the fractured bone is slowly raised taking care not to damage the underlying
meninges. A variation or degeneration of the boring-and-cutting operation
existed until recently in North Africa. Hilton-Simpson, studying the practice
of trepanation among the Kabyles in Algeria, found that the procedure
consisted in removing a circular portion of the scalp with a cylindrical
iron punch that had been heated red-hot. Retractors were used to draw
away the scalp, and next a small opening was cut in the skull by the confined
use of a small drill which was spun between the palms of the hands. With
a saw a small incision was made and care taken not to injure the dura
mater. Each succeeding day the sawing process was repeated until the piece
of bone to be removed was loose, this could take anything from fifteen
to twenty days. Finally the part sawn away was lifted from the skull by
an elevator. 4. The use of a trepan to remove a disc of bone from the
skull (this method is not illustrated here). This instrument seems to
have been in current use in ancient Greece and at a later period in Rome.
Hippocrates advised its use for a variety of head injuries, and stated
that the craniotomy should be so performed that the trepan does not penetrate
too quickly to the dura mater and that the cut fragment should be allowed
to detach itself. During the operation the instrument was to be plunged
frequently into cold water to avoid overheating the bone (Littré). According
to Spencer, Celsus recommended the "crown trepan" or modiolus for treating
smaller cranial injuries. A modiolus is a hollow cylindrical iron instrument
whose lower edges are serrated and down its centre runs a fixed pin which
is itself surrounded by an inner disc. As mentioned previously, for more
extensive head trauma Celsus suggested the boring-and-cutting treatment.
A method in which four straight incisions are made, intersecting at right
angles and the in-between fragment is removed (Fig. 1, number 4). This
procedure was commonly adopted in Peru, though isolated finds of this
type occur also in other parts of the world. Terrier and Péraire (1895)
described such an example from Lizières in France dating to the Neolithic
period. As already mentioned, from Palestine Parry and Starkey reported
on two Iron Age skulls found by Risdon, and Giles described a further
discovery from there showing an attempt at such an operation. Forgue notes
that this type of procedure was also carried out by the Kabyles in Algeria;
and according to Sood one skull from Kenya shows an attempt at such an
intervention. Rytel (1962) believes there has been what one might call
an evolutionary trend in the methodology of trepanation. He considers
that the earliest operative procedure began with rectilinear cranial incisions
resulting in rectangular openings. This form of craniotomy then proceeded
through the polygonal to the circular type of orifice. It was followed
by a method of scraping away the bone with a rotatory technique thus making
the hole lenticular, oval or circular in shape. And finally the practice
evolved to the boring-and-cutting method described above and recommended
by Celsus and adopted later by mediaeval surgeons. Various attempts have
been made to assess the time it took to perform a trepanation. Broca,
repeating the procedure experimentally on adult post-mortem skulls, found
that it took anything from thirty minutes to one hour to perform the operation.
About the same length of time was also taken by present-day Peruvian surgeons
when trepanning living heads with primitive implements under aseptic conditions
(Cabieses). Lucas-Championnière found that the grooving technique took
more than one hour to perform and therefore favoured the boring-and-cutting
procedure as the method of choice in pre-historic times. At the other
extreme is the method used by the Kabyles who, cutting little by little
each day, could take up to twenty days to complete the operation. The
diameter of the trepanations varies from that of a small drill hole, a
few millimeters across, to quite large openings of 82 mm x 62 mm (Regnault)
or larger (Boev), thought they are on the average between 30 mm to 45
mm across, one axis being longer than the other. Thus their shapes are
frequently oval (in these cases the longer diameter tends to be anteroposterior)
or triangular, the smaller openings tending to be round. Quandrangular
orifices are produced by four right-angled intersecting incisions. The
majority of trepanned specimens show single openings. The skull with the
highest number of trepanations so far discovered was reported by Oakley
et al. And came from Cuzco in Peru. This has seven healed openings. Examples
with two to three or even as many as five craniotomies have been found
in various parts of the world. Brief mention must now be made of the postoperative
treatment of trepanations. Although Forgue (1938) inferred from analogy
with present day practices that the early medicine-men used powdered charcoal,
hot sand, cedar wood resin or even cinders from sacrifices for their dressings,
this can only be conjecture. With regard to the actual trepanned opening
Thompson (1938) considers that this was closed with a plate made from
shell or other substances and that in some cases even a lead or other
metal (Rytel) diaphragm was used, though Stewart believes that there is
no good evidence of this practice. For haemostasis the Inca are reputed
to have used extracts from the Ratania root and Pumacbuca shrub of the
Andes which are rich in tannic acid (Rytel). Celsus recommended the use
of vinegar to stop bleeding (Spencer). Although hardly anything is known
of the ancient postoperative treatment of trepanations information on
actual practices is available from Algeria and Melanesia. Hilton-Simpson
(1913) reports that for dressings the Kabyles used daily applications
of heated honey and butter and the stem of leaves belonging to the species
of labiatae. This dressing was continued sometimes for as long as a month.
Detailed accounts from Melanesia are given by Crump and Ford. The trepanned
opening was washed with water of the unripe coconut, plugged with a piece
of bark cloth and then covered with part of the inner bark or leaf of
the banana palm which had been held over a fire. Then the skin flaps were
replaced and stitched with a needle, the latter being made in some cases
from the wing bone of a flying fox. And finally the head was bound with
dried strips of banana stalks.

Schröder (1957), dealing with the healing of trepanations, found that
the endosteal callus produced by the diploë is small in amount and that
the periosteal callus of the epicranium grows only very little. Thus the
osseous regeneration is rather sparse. Apart from a few osteophytes the
reaction at the margins of the opening only amounts to a very few millimeters.
Similarly Pritchard (1946) has been able to show experimentally that in
skull fractures in rats new bone formation is slight and confined to the
fracture site when healing is uncomplicated by widespread haemorrhage
or infection. In the latter event there is widespread subpericranial new
bone formation with bone resorption. The immediate bony area around the
trepanation is radiologically more transparent from the periphery to the
margin of the hole (Schröder). The same author warns that radiological
differentiation between post-mortem and intro-vitam craniotomy is practically
impossible and that Guiard went too far in his claims. The latter believed
that he could differentiate radiologically whether an individual had survived
the operation for several weeks, months or at least one year. The main
diagnosis of healing at the margins is the macroscopic observation of
the spongy diploë, the presence of occasional osteophytes and the character
of the edges of the external and internal lamina. Healing is indicated
by a closed or closing diploë and relatively smooth borders. The region
around some trepanations shows a circular area of osteitis surrounding
the opening (Stewart, 1956). This takes the form of an osteoporotic pitting
which can be seen as a halo around the craniotomy. The borders of the
osteitis correspond to the edges of the orifice made in the scalp preparatory
to trepanning. According to Stewart the halo indicates that the individual
had lived after the operation and that some degree of infection had set
in afterwards. Although it has been suggested that this is a chemical
osteitis resulting from applications of medicaments to the wound, Stewart
believes it is more likely a septic osteitis. Thus when making a detailed
study of this operation it is necessary to examine carefully the margins
of the trepanation and the surrounding area of bone. The survival rate
following craniotomy was remarkably high as evidenced by skulls showing
healed openings. Stewart, examining 214 trepanned skulls from Peru belonging
to three collections in the United States, found that 55.6 per cent show
complete healing, 16.4 per cent early stages of healing and 28 per cent
no healing. Rytel too attests to the surgical skill of the Peruvians,
of 400 trepanations 250 (62.5 per cent) showed healing. When examining
the figures of Russu and Bologa one finds that of the Neolithic material
two survived, one lived for a while and four died, whilst of the Mediaeval
examples two survived and one died. The figures of Brunn show that thirteen
survived and only three died, his material dates from the Neolithic to
circa sixth century A.D. And comes from central Germany. And according
to Crump the mortality rate was about 20 per cent in New Britain, in fact
many deaths resulted from the original injuries rather than from the operation.
The remarkable skull from Peru with seven healed trepanations and reported
by Oakley et al. Is proof of the skill of the early surgeons. In Kenya
quite a number of individuals walk around having recovered from their
second or even third trepanation (Sood). The cause of death was very often
the original injury. Complications from the actual operation such as haemorrhage,
brain damage, sever shock, sepsis and meningitis further contributed to
the mortality rate.

Broca erroneously believed that the early surgeons trepanned mainly children
and adolescents and he considered that this was due to the frequency of
juvenile convulsions. However, the discoveries since have disproved this
idea. Certainly children were trepanned and evidence for this is available
from Peru (Stewart) and from Melanesia (Ford) where it was also practised
prophylactically as cited above. According to Guiard the practice of trepanation
coincided with the presence of a dominant brachycephalic element but was
absent from countries where a dolichocephalic population predominated.
However, a careful examination of the material shows that this operation
was also practised in those parts of the world where dolichocephalic and
mesocephalic peoples were the dominent element. In connexion with trepanation
in man mention must also be made of the practice in sheep. Although Ruffer
states that is was done for the relief of staggers, he felt that the theory
of the veterinary origin of trepanation in man was purely hypothetical.
In Rumania craniotomies were performed on sheep by shepherds since ancient
times (Russu and Bologa) for the treatment of staggers. This disease which
manifests itself by swaying and an uncertain gait is caused by Coenurus
cerebralis, the larva of the Taenia coenurus (Multiceps multiceps) found
in the brain of sheep, goats and other ruminants. According to the authors
the skull is opened with a knife made of soft iron and the larvae are
removed. However, only a few animals recover.

It is a fact that many unusual openings have been reported as true trepanations,
although originating in devious ways. Thus the differential diagnosis
is of some importance. Admirable attention has already been drawn to this
in the exhaustive studies of Guiard and of Giot and Desse. Openings in
the skull may be produced by infective processes such as tuberculosis,
syphilitic gummata, localized osteomyelitis, or mycoses or as a result
of tumours like epidermoid and dermoid cysts, myelomas, secondary carcinomas
and sarcomas. Traumatic conditions at birth or during early childhood
may also appear as trepanned holes. Bircher (1908) has shown that some
so-called trepanations in adults are the results of the use of certain
weapons peculiar to the Middle Ages. Brothwell has also drawn attention
to the action of beetles and porcupines or other rodents that can produce
extensive destruction of bone. Similarly he points out that artefact openings
may be due to a pick or other tool used during disinterment, or the cause
may be a continual pressure of a sharp stone, or selective erosion of
one region of the skull, all or which can give rise to a hole that may
bear strong resemblances to a trepanation. There are, however, three conditions
that may give rise to mistakes in diagnosis since they occur in association
with the parietal bone. These are enlarged parietal foramina, "Fenestrae
parietalis symmetricae," and bilateral osteoporosis ("thinning") of the
parietal bone. Normally the parietal foramina are very small, but occasionally
they may have a diameter or two or three centimetres (Broca, 1875; Spee,
1896; Le Double, 1903), this enlargement being due to a defect in development.
According to Spee these sort of foramina are more frequent in males and
on the right side. Apart from size, their site and number may vary too
(Le Double), and the anomaly may also be hereditary (Weber and Schwarz,
1935). Cave (1928) has even reported two cases with bilaterally enlarged
parietal foramina. These types can be easily mistaken for a trepanation.
An example of this error is an Egyptian female skull of Roman date (c.
200 A.D. ) found at Shurafa, Lower Egypt, with an enlarged right parietal
foramen. This was reported by Derry (1914) as due to a dermoid cyst and
considered as a trepanation by Horsley (1888). With regard to "Fenestrae
parietalis symmetricae" also known as "Catlin mark" (After an American
family in whom this character occurs) quite a different situation obtains.
Goldsmith (1941), who has also reviewed the literature, considers that
this bilateral anomaly and the normal but highly variable paired parietal
foramina are not one and the same thing, but have different origins though
anatomically they may fuse. In fact he knows of skulls that show both
the fenestrae and the enlarged parietal foramina. The fenestrae are oval
to round in adults and have definite "healed" edges, and in the living
head they are covered with skin and dura mater, but are clearly demonstrable
radiologically. There seems no doubt that this condition may arise as
a sport or a mutation. According to Goldsmith a survey of various collections
of human skulls shows that the trait is not uncommon and that many supposed
cases of trepanation really represent this hereditary anomaly. The third
condition which often gives rise to mistaken diagnosis is that of osteoporosis
of the parietal bones. Although considered elsewhere in this book by Lodge
(pp.405) it seems worth considering the subject a little here since osteoporosis
is found fairly frequently in ancient skeletons (Eve, 1889; Elliot Smith,
1906) and can so easily be confused with healed trephine openings. This
manifests itself as a rarefaction of bone, due to diminished osteoblastic
or increase osteoclastic activity, which results in a reduction in the
amount of total bony substance without evidence of mineral deficiency
(Schmidt, 1937; Grollman, 1963). Osteoporosis generally commences in those
parts of the skeleton that are subjected to the greatest stress, e.g.,
the thoracic region of the vertebral column. However, ultimately it will
involve other skeletal parts and even the skull. There is increased porosity
and a decrease in the thickness of the cortex of the bone. Aetiologically
the imbalance between osteoblastic activity and osteoclastic dissolution
is the consequence of a variety of causes which will be mentioned briefly.
(1) Nutritional deficiencies in vitamins, calcium and proteins will result
in rarefaction of bone. Thus for example a lack of calcium may be demonstrated
in individuals manifesting so called idiopathic, senile or postmenopausal
osteoporosis (Grollman). Already long ago Lobstein (1834) and later Paget
(1870) and Ferré (1876) suggested that osteoporosis of the parietal bones
was due to senile atrophy. (2) Endocrine disturbances such as hyperthyroidism,
hyperparathyroidism, acromegaly and Cushing s syndrome are often accompained
by osteoporosis (Grollman). (3) Congenital deficiency of osteoblastic
function may also give rise ro rarefaction of bone. This may also be hereditary
as pointed out by Shepherd (1892) and Roger and Schachter (1941). (4)
Reduced mechanical stress according to Grollman can also be a cause of
osteoporosis. The characteristic location of osteoporosis in the skull
is in the parietal bones between the sagittal suture and the parietal
eminence on both sides. In some cases the temporal, or frontal, or occipital
bones may be involved bilaterally. The parietal osteoporosis forms a depression
which is roughly triangular, quadrilateral, or trough-like in shape (Greig,
1926). There is no sharp line of demarcation between the depression and
the adjacent normal external lamina and therefore the margins shelve gradually
into the thinned area. Radiologically there is a general reduction in
the density of the bone which becomes thin. Greig and Durward (1929) have
drawn attention to the fact that the parietal foramina are not involved
since the thinning process leaves a margin of bone about one centimetre
in width. With regard to the incidence of osteoporosis of the parietal
bones, Camp and Nash (1944) found that one in two hundred and seventeen
heads showed this trait on radiological examination, with a mean age of
over fifty years. And Humphry (1874) found that this abnormality is not
confined to the human species only but is also present in the orang-utan.
The error in diagnosing a trepanation is due to the fact that in parietal
osteoporosis the normal bone shelves into a thinned area which is extremely
fragile. The latter then breaks down post-mortem for one reason or another
and leaves an opening with a more or less bevelled circumference and apparently
healed. This type is exemplified by an Egyptian skull of the twelfth Dynasty
(c. 1900 B.C. ) and reported as a trepanation by Breasted (1930), its
true condition was later diagnosed by Stewart (1952).

This mutilation, practised in Neolithic times, is in the form of a T
or L and consists of a series of cauterizations of the skin affecting
the periosteum (Manouvrier, 1895). One line runs antroposterior following
the sagittal suture and the other is at right angles and joins the two
parietal eminences. In the majority of cases the operation was performed
on women. As Stewart rightly points out, any damage to the scalp leading
to a loss of blood supply to the bony vault may be followed by osteitis
which can result in scarring of the bone. It is known from surviving medical
records that in Mediaeval Europe thermal and chemical cauterization was
applied to the head in cases of epilepsy and dementia (MacCurdy, 1905).
Piggott remarks that there may have been some connexion between these
mutilations and the practice of the tonsure. One might even ask the question
whether this might not have been a form of baptism or branding. The examples
of sincipital mutilation are few in comparison to the number of trepanations.
According to Manouvrier (1895) this practice was restricted to a district
north of present day Paris between the Seine and Oise. From Hungary Bartucz
(1964) has reported one case and Zaborowski (1897) mentions that to the
west of the Caspian Sea, the inhabitants of Dagestan practised a form
of cauterization of the vertex of the head, similar to the sincipital
operation, in order to prevent illness.

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